Practice Recommendations 
                                
             for the Nutritional Management of 
                                
                Anorexia Nervosa in Adults 
                                
                                
                                
                                
                                
                                
                                
                           Developed by 
                                
                   Alison Wakefield APD & Hazel Williams APD 
         
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        Contents 
         
         
         Executive Summary ............................................................................................. 1 
         
         Introduction .......................................................................................................... 6 
         
         Recommendations and Evidence ...................................................................... 14 
         
         General Practice Recommendations ................................................................. 17 
         
         Summary of Practice Recommendations ........................................................... 17 
         
         Appendix 1: Background to Practice Recommendations and Practice Tips ....... 19 
         
         Appendix 2: Assessment details ........................................................................ 36 
         
         Appendix 3: Diagnostic Criteria .......................................................................... 38 
         
         Appendix 4: Psychology of starvation ................................................................ 40 
         
         References ......................................................................................................... 41 
         
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                                           List of Tables 
                                                   
             
            Table 1: Consultation and Development of Recommendations .................................. 9 
             
            Table 2: NHMRC levels of evidence 1999 Definition of Evidence Categories1 ......... 14 
             
            Table 3: NHMRC Additional Levels of Evidence and Grades 2005-2007 Pilot 
                            2
                    Program  .................................................................................................... 14 
             
            Table 4: Summary of papers reviewed for evidence in nutritional management of AN
                 .......................................................................................................................... 15 
             
            Table 5: Biochemical measurements for diagnosis19 ................................................  20 
             
                                                      19
            Table 6: Other medical parameters for diagnosis  .................................................. 22 
             
            Table 7: Anthropometric, biochemical and medical intervention19 ............................ 24 
             
            Table 8: Dietary History and Nutritional Assessment ................................................  36 
             
            Table 9: Some of the abnormal eating behaviours in anorexia nervosa ................... 37 
                                                   
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                         Executive Summary 
                          
                         These recommendations aim to support dietetic practice, identify gaps in knowledge 
                         and evidence based practice, and to indicate potential areas in need of research for 
                         the dietetic management of adults diagnosed with anorexia nervosa. The 
                         recommendations can also be adapted for use with people who have sub-clinical AN 
                         or Eating Disorders Not Otherwise Specified (EDNOS). The expected health benefits 
                         of the recommendations are to minimise nutritionally related medical complications of 
                         the illness and facilitate nutritional and medical recovery. Anorexia nervosa is part of 
                         a wider spectrum of eating disorders such as Bulimia Nervosa (BN) and Binge Eating 
                         Disorder (BED) which are not covered in these practice recommendations. 
                          
                         Management of adult anorexia nervosa is across many settings from inpatient to 
                         community-based clinics. Nutritional management should always be provided in 
                         collaboration with medical and psychological therapies. 
                          
                         A number of clinical questions were developed during a series of workshops with 
                         dietitians working in the area of anorexia nervosa. These questions are:  
                         •     What specific measures best reflect nutritional status, abnormal eating behaviours 
                               and abnormal attitudes in patients with anorexia nervosa? 
                         •     What are the defining diagnostic characteristics that describe the nutritional 
                               status, abnormal eating behaviours and abnormal attitudes in adult anorexia 
                               nervosa patients? 
                         •     What are the requirements of the dietitian treating anorexia nervosa in adults? 
                         •     What are the appropriate nutritional interventions to optimise nutritional status? 
                         •     What are the ways that dietitians can help patients achieve normal eating 
                               behaviour and normal attitudes to food? 
                         •     What are the outcomes to be monitored and evaluated to determine the progress 
                               of nutritional care in adult patients with anorexia nervosa? 
                          
                         Despite a wide literature search very little research was found associated with 
                         dietetic practice in the management of anorexia nervosa. No levels of evidence 
                                                                1,2
                         (NHMRC 1999, 2005)  could be assigned to any of the clinical questions, due to the 
                         lack of suitable research studies. The literature search generated 947 articles but 
                         after exclusion criteria only four are used in these recommendations. The lack of 
                         randomized clinical trials (RCT) for any type of clinical management of anorexia 
                         nervosa makes the writing of evidence based guidelines for dietetic practice 
                         impossible. Therefore these recommendations are based on universal standards of 
                         best practice developed through a process of extensive consultation with dietitians 
                         and health professionals working in this area and related consumer associations to 
                         create recommendations, based on consensus of expert opinion. 
                          
                         The recommendations cover three main areas: 
                               1.  Appropriate access to care 
                                           • Nutritional Status 
                                           • Eating behaviours 
                                           • Attitudes 
                               2.  Quality nutrition care 
                                           • Diagnostic characteristics 
                                           •     Requirements dietitian treating AN in adults 
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